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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />zl£ • . / <br />APN <br />^Change of Owner Consultation Repairs or Remodel Other <br />VIN <br /> Architect Billing Party Facility Owner Facility Contact Property Owner Contractor <br />Facility Contact Property Owner Contractor Architect. Billing Party <br />If contractor, indicate type and license number <br />tnc-cf k <br />Billing Party Contractor Architect Facility Owner Facility Contact <br />If contractor, Indicate type and license number <br /> Billing Party Facility Owner Property Owner Contractor <br />First Name Last name <br />City ZIPAddressState <br />Phone Phone Email <br />DATE: <br /> PROPERTY / BUSINESS OWNER <br />Accepted By Assigned To <br />Fee1^02- <br /> Check fl <br />Rev 07/10/2024 <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />|~c-? |/y <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it Is available and at the same time it is provided to me or my representative. <br />State <br />CA <br />State <br />State <br />GPFacility Owner <br />Type of Service <br />Requested <br />Comments <br />PE <br />Title <br />First Name <br />u?i <br />t Phone <br />Application Form <br />LWO palp's (ZlT'ak/ <br />toco pY IWP <br />Supervisor District <br />First Name <br />Address <br />1 <br />Phone <br />lf mobile food truck or <br />pumper truck <br />AddressM3 <br />Phone <br /> Cash <br />License Plate Number <br />Site Address <br />a <br />PhoneM <br />Email <br /> Property Owner <br />} fConfirmation it <br />City <br />L\l/KF2>^ <br />Email . .ao'iT^.qi/Uyn(g cis ■ cei^ <br /> Facility Contact <br />City <br />Last name <br />City <br />Last name <br />PWIUaN <br />Linked FA4D* —AV <br />Record Number <br />SU2.5Q>\Z-Z\__________ <br />Payment jCZ2\_ - <br />Received By <br />DA payment <br />If contractor, indicate type and <br />JUN ^5 20;5 <br />___________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site arld/W^rtARTAff "lay <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this ’ 1 <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. A\ zt- /'} <br />APPLICANT'S SIGNATURE: <br />□ OPERATOR / MANAGER E^f OTHER AUTHORIZED AGENT